Patient Data

The nurse has received initial prescriptions for the client and is planning nursing care.

Select 2 outcomes that would be appropriate for the nurse to include for this client's plan of care.

Weight will remain unchanged

Oxygen demands will increase

Urine output will increase

BNP level will decrease

Lung sounds will remain unchanged

Potassium level will decrease

Answer and Explanation

Correct Answer : C,D

A. Weight remaining unchanged is not the most appropriate outcome. In clients with fluid overload or heart failure, the goal is to monitor for weight changes to assess fluid balance. The expected outcome might be weight reduction or stabilization depending on therapy, rather than simply remaining unchanged.

B. Oxygen demands increasing is undesirable. The client’s goal is to improve oxygenation and reduce respiratory distress, so increasing oxygen demand would indicate worsening condition rather than improvement.

C. Urine output increasing is an appropriate outcome. Diuretics are commonly used to treat fluid overload in clients with heart failure. Increased urine output indicates effective diuresis, improved fluid balance, and renal perfusion, which are signs of positive therapeutic response. Monitoring urine output helps the nurse evaluate the effectiveness of treatment and detect early complications.

D. BNP (B-type natriuretic peptide) levels decreasing is another appropriate outcome. BNP is released by the ventricles in response to increased pressure and volume overload. Elevated BNP indicates cardiac stress and heart failure. A decrease in BNP reflects improved ventricular function and reduced fluid overload, demonstrating that interventions such as diuretics, ACE inhibitors, or other heart failure treatments are effective.

E. Lung sounds remaining unchanged is not a desirable outcome if the client presents with abnormal findings such as crackles or wheezes. The goal of therapy is usually to improve lung sounds by reducing pulmonary congestion and edema.

F. Potassium levels decreasing is not an appropriate outcome because hypokalemia can result from diuretic therapy and may lead to dangerous cardiac arrhythmias. The desired outcome is maintaining potassium within a safe range.

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Correct Answer is D

Explanation

A. Palpating the popliteal pulse can provide information about circulation, but it does not give an accurate blood pressure reading. Using this method alone is not sufficient for documentation of the client’s blood pressure.

B. Estimating blood pressure based on radial pulse volume is unreliable and can lead to inaccurate assessment and unsafe clinical decisions. Blood pressure must be measured using validated methods.

C. Documenting the last recorded blood pressure without attempting an accurate measurement is inappropriate because it does not reflect the client’s current condition and could lead to unsafe care.

D. Documenting why the blood pressure cannot be accurately measured is the correct action. This communicates the limitation to the healthcare team, ensures patient safety, and provides justification for alternative monitoring strategies until an accurate measurement can be obtained, such as using a thigh cuff or waiting until the client can be positioned appropriately.

A. A B. B C. C D. D

Correct Answer is D

Explanation

A. A dressing that is saturated with sanguineous drainage must be placed in a Biohazard Bag (commonly referred to as a "Red Bag"). Standard nursing practice dictates that any item "dripping, saturated, or caked" with blood or potentially infectious material (OPIM) must be disposed of in a biohazard container.

B. A dressing that is saturated with sanguineous drainage must be placed in a Biohazard Bag (commonly referred to as a "Red Bag").

C. A dressing that is saturated with sanguineous drainage must be placed in a Biohazard Bag (commonly referred to as a "Red Bag").

D. A dressing that is saturated with sanguineous drainage must be placed in a Biohazard Bag (commonly referred to as a "Red Bag"). Standard nursing practice dictates that any item "dripping, saturated, or caked" with blood or potentially infectious material (OPIM) must be disposed of in a biohazard container. Sanguineous drainage contains high concentrations of red blood cells and potential pathogens. Placing these in a standard bedside trash can increases the risk of cross-contamination or accidental exposure during waste removal.

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Patient Data The nurse has received initial prescriptions for the client and is planning nursing care. Select 2 outcomes that would be appropriate for the nurse to include for this client's plan of care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is D

Explanation

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Correct Answer is D

Explanation

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Patient Data

The nurse has received initial prescriptions for the client and is planning nursing care.

Select 2 outcomes that would be appropriate for the nurse to include for this client's plan of care.